Pre-intubation Checklist by Dr. Traci Wolbrink.
Hi, my name is Traci Wolbrink, and I'm one of the pediatric intensivists at Children's
Hospital Boston.
In this video, I'm going to be talking to you about the pre-intubation checklist that
we use here at Children's Hospital Boston.
In this video, I'm just going to be animating the pre-intubation checklist, and going through
with you how we proceed with going through this before every patient that we intubate
here in our intensive care unit.
We often have the pre-intubation checklist with us at the bedside as we go through it,
to make sure that all of our care providers, from physicians, nurses, respiratory therapists,
and clinical assistants, so that everybody is on page with what we're doing in terms
of intubation, and what resources we might need available during the procedure.
Role assignment.
To begin with, once we've decided that we want to intubate a patient, we want to make
sure that we have all the available equipment, resources, and personnel that we need to safely
intubate a patient.
So we begin by going through our checklist.
And as I look at the checklist, the first thing that we look at is we assign roles,
different people to perform different tasks during the intubation.
So first of all, someone identifies themselves as the physician leader.
Typically, this is an attending physician, or a senior fellow, or one of the senior doctors.
This person should also delegate a different doctor preferably, to be a laryngoscopist.
And there should also be a backup laryngoscopist.
There should also be someone that can prepare the medications.
There should be someone that's going to administer the medications.
There should be someone that can provide cricoid pressure if necessary.
Someone that will play the role of the respiratory therapist, including making sure that we have
a ventilator available and set up, and that we have a end-tidal CO2 detection machine
or device available.
And that we have one person who's going to assess the patient during the procedure, watching
for the patient's vital signs to change, or any other problems that might arise during
the intubation.
Once we've clearly identified somebody to fulfill all of these roles, and those roles
are clearly defined, and the person performing the tasks are ready to begin the procedure.
At that point, then we can proceed with going through the rest of the checklist.
Patient Assessment.
The second part of the checklist is the patient assessment.
First, are there any difficult airway concerns?
Does this patient have any anatomical problems that might make us worried that we may have
a difficult time intubating the patient?
Does the patient have a small jaw?
Does the patient have midface hypoplasia?
Does the patient have poor mouth opening?
Does the patient have poor range of motion?
Is the patient scoliotic?
Is there kyphosis or any other structural or skeletal abnormalities that might make
us alert to this being a difficult airway?
Additionally, things like contractures or burns-- those will also be important to know.
Does the patient have any concerns for airway edema?
Have they had an inhalation injury?
Do they have epiglottitis?
Or do they have a tumor, a large mass, a vascular malformation of the tongue or oropharynx?
All of these things will be important to recognize, prior to attempting to intubate this patient.
Additionally, if you have the records available and this patient has previously been intubated,
you can check to see whether this patient was an easy intubation in the past, or if
there were some difficulties.
You may also be able to assess what size blade they have used in the past, successfully,
or what maneuvers may have worked to be able to visualize the larynx for this patient.
If there are any concerns that this patient may have a difficult airway, you want to make
sure that you have a very experienced laryngoscopist present.
And you may need to think about other ways to perform intubation for this patient.
Is this a patient that might need a fiberoptic intubation, an awake intubation, or other
devices-- such as a glide scope or other commercially-available products that are useful for a patient with
a difficult airway.
You should know these ahead of time, so that you can be prepared for the intubation.
The next thing you'll want to evaluate is, do you have any concerns for a full stomach?
You want to make sure that you know what time the patient last had something to eat or drink.
In an emergent intubation, you don't have the luxury of waiting four or six hours after
the time of the last oral intake.
This patient emergently needs intubation.
And you'll want to take any measures you can to try to prevent the regurgitation of food.
You can try to limit the amount of pressures that you do in the bag.
And although it's debatable, you can perform some cricoid pressure.
Also, if the patient has a gastrostomy tube, you'll be able to vent this tube.
And that way, if you deliver any air through bag mask ventilation into the stomach, you'll
be able to release that air by venting the gastrostomy tube.
The next step when you're ready to begin is getting the patient in proper positioning.
So you want to make sure that you can see the chest, so you can know whether or not
you have adequate chest movement when you're doing bag mask ventilation.
So you want to make sure that you remove the clothes of a patient.
If the patient has a gown, open it.
If the patient has clothes on and you emergently need to intubate this patient, cut off the
clothes.
You want to make sure that you can see the chest, and that you have access to sites for
peripheral pulses, as well as for central pulses.
In addition to exposing the chest and pulses of a patient, you want to make sure that you
properly align the axes of the airway, in order to properly intubate this patient.
You want to make sure that you put the patient into sniffing position.
And depending on the age of the patient, that may require a head roll, a roll behind the
back.
It depends on the age and body habitus of your patient, what you might need.
But you want to make sure those axes are aligned before you begin to perform your laryngoscopy.
Additionally, it's very important to have someone performing cricoid pressure, that's
familiar with performing the burp positioning-- which means once you have your fingers on
the cricoid cartilage, that you move the cricoid cartilage backwards, upwards, and right position--
which will allow you to move the airway into better view of the person that's performing
the laryngoscopy.
Please note that burp refers to the patient's right.
The next step is to assess the patient's physiological status.
What is their cardiovascular status like?
Are they hypovolemic?
Do you have concerns about preload?
And when you give them positive pressure ventilation, are they going to become quite hypotensive?
Should you give them volume, or start vasoactive agents prior to the intubation?
Additionally, do you have any afterload concerns?
How is their right ventricle?
How is the function of the right ventricle?
Are you going to harm them if you give them positive-pressure ventilation?
Those are the things that you want to discuss, prior to beginning your laryngoscopy and when
choosing your medications.
Additionally, are there any neurological concerns?
Does this patient have any indication that they may have an elevated ICP?
You may want to choose a different medication based on what your concerns, from a cardiovascular
and a neurologic standpoint.
Additionally, are there any other organ failures?
Does the patient have hepatic failure or renal dysfunction?
All of those are going to influence your choice of medication.
Next step-- you want to evaluate the patient's access.
Do you have an IV, in order to give medications?
Is this IV functioning?
When was the last time it was checked?
You want to make sure you have a safe and stable way to provide medications during your
procedure.
Equipment and monitoring.
The next step is to make sure you have an appropriate equipment and monitoring for your
procedure.
You want to make sure that the patient has ECG leads in place.
You want to make sure that the patient has their saturation probe in place.
And you want to make sure that you have some way to monitor your end-tidal CO2 after the
intubation attempt, whether that's a cap device that changes colors in the presence of CO2
or an end-tidal CO2 monitor.
You should have something available in order to confirm your endotracheal tube placement.
You should make sure you have equipment ready.
So the common equipment that you need to have at the bedside is going to be a suction catheter,
a bag, an appropriate size mask for the patient, a laryngoscope, an appropriate size endotracheal
tube, with a size larger and a size smaller, a stylet, and an oral airway.
All of these will help to both bag mask ventilate a patient, as well as to perform the laryngoscopy.
You should also make sure that you have your bag mask ventilation system connected to an
oxygen source so that you can pre-oxygenate your patient before beginning the procedure.
Medications.
The last step is medications.
In this step, the physician leader will state in which order the medications will be administered,
and they will describe again any of the pertinent considerations including cardiovascular, neurological,
or organ failure considerations that will need to be addressed by the medications.
Typically the pre-medication is given first, followed by a hypnotic and a neuromuscular
blocking agent.
And once you've addressed all of these items on your pre-intubation checklist, then you
can proceed with performing the procedure.
So this concludes our video on the pre-intubation checklist.
Thank you.
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